Readmission and the social construction of mental disturbance
D Litt et Phil Dissertation, University of South Africa, 1999
TABLE OF CONTENTS
Chapter Page
Preface: A visit to the aquarium 1
1. Readmission: An overview of empirical research 6
Deinstitutionalisation 10
Predicting and preventing readmission 13
Demographic factors 14
Diagnosis 15
Length of hospitalisation 17
Quality of aftercare 18
Medication 19
Previous admissions 20
The Family 20
Expressed Emotion 22
Integrating empirical findings 23
From readmission to chronicity 24
2. An archaeology of psychiatric readmission I: The 18th and 19th centuries 26
Free at first: Madness before the Enlightenment 28
The Great Confinement 30
Curing the insane I: The eighteenth century 33
Turning the subject: George III and the mad-doctors 36
Breaking their will: Pinel and the liberation of the insane 38
Madness reduced to silence: The York Retreat 43
Asylum-building in the nineteenth century 45
Curing the insane II: The nineteenth century 51
The terrifying system 57
3. An archaeology of psychiatric readmission II: The 20th century 67
Deinstitutionalisation 74
The end of deinstitutionalisation I: Lost to aftercare 80
The end of deinstitutionalisation II: The timeless trajectory 84
Conclusion: Free at last 95
4. Poised on the brink: The social construction of a New Biological Psychiatry 98
'Specific questions of fact': The logic of scientific discovery in psychiatry 103
'A strange antirational period': Discounting the recent past 109
'A thing of the past': Millenarian qualities of the New Biological Psychiatry 116
'More than a science': The new anti-biopsychiatry 119
5. Beautiful and inexorable systems: The discourse of discourse analysis 128
'Stammered, imperfect words without fixed syntax': The language of psychiatry 132
'To penetrate the veil while retaining its hallucinatory quality':
The language of medicine 135
'Neither difficult nor contentious': The language of linguistics 139
'A bit like a whale': Postmodernity 143
'The knowledge that one seeks to disinter': The language of discourse analysis 147
6. Objective tools for analysing linguistic structures 160
Corpus studies 161
Word frequencies and type-token ratios 168
Concordances and collocations 171
Automated and semi-automated tagging 174
Content analysis 179
Towards a quantitatively informed discourse analysis 181
Corpus linguistic techniques adapted for discourse analysis 189
Manual annotation 189
'Root form' and 'Parts of speech' lemmatisation 190
Frequency counts 192
Target-word collocations 193
Collocation counts 193
Contextual markup 194
Lexical nets 195
Z-scores 195
Conclusions 197
7. 'The unreturning stylus': Interviews with psychiatric patients 198
'Subjects and sampling' 204
The interviewing process 208
Transcription 214
Analytic strategy 215
Preliminary quantitative overview of the first interview corpus 217
Getting into the text 220
Getting to know you 224
The blues 230
Mommy daddy me 234
The oracle speaks 239
Before and after 243
Preliminary quantitative overview of the reason for admission corpora 245
Being there 251
Working hard; stressed out 252
Breaking free 256
Conclusion: No looking back 258
8. 'Apparently a known schizophrenic': From confession to surveillance 261
'Subjects and sampling' 262
Analytic strategy 266
Getting into the text 266
Preliminary quantitative overview 269
'Presenting problems' 273
Histories of the present 276
Histories of the past 280
Familiar to the system 282
Conclusion: The timeless trajectory 286
9. Conclusion: The prison house of language 288
Methodological commentary 290
Afterword 294
References 296
Appendix 1: Interview consent form 333
Appendix 2: Choice of parameters in drawing up a lexical net 334
Appendix 3: Significant collocates in first interview transcript 346
Appendix 4: Sample interview 352
Appendix 5: Significant collocates in the initial history corpus 358
Page
Figure 2.1 Patients in public asylums in England and Wales, 1850-1930
(source: Scull, 1984) 50
Figure 2.2 Percentage of admissions discharged as "recovered" from
the Worcester State Hospital (source: Warner, 1994) 55
Figure 3.1 State mental hospital census in the United States of America
(source: Barham, 1992; Scull, 1984) 75
Figure 3.2 Mental hospital population in England and Wales as a proportion
of the total population (source: Barham, 1992) 77
Figure 3.3 A life line (from Quam & Abramson, 1991) 93
Figure 3.4 Life line of a 65-year-old male (from Quam & Abramson, 1991) 94
Figure 6.1 Surface structure and deep structure for three components of language
(from Longacre, 1976) 165
Figure 6.2 Sample type/token graph 170
Figure 7.1 Lexical net of the first interview corpus 223
Figure 7.2 Lexical net of the first reason for admission corpus using a span
of 8 and minimum collocation frequency of 5 250
Figure 7.3 Lexical net of the second reason for admission corpus using a span
of 8 and minimum collocation frequency of 5 250
Figure 8.1 Lexical net of the initial history corpus 273
Page
Table 5.1 Characteristics of Modernity versus postmodernity
(adapted from Brooker, 1992) 144
Table 5.2 The community repertoire (from Potter & Reicher, 1987, p. 32) 150
Table 6.1 Sample word frequency list from two pages of text 168
Table 6.2 Part of a concordance for the King James Bible 172
Table 6.3 Grammatical and ambiguous words (adapted from Butler, 1985) 192
Table 7.1 Discharge diagnoses of patients at Valhalla hospital 202
Table 7.2 Discharge diagnoses of interviewees and of the ward as a whole 205
Table 7.3 Biographical details and discharge diagnoses of interviewees 207
Table 7.4 Sixty most common types in the first interview corpus 218
Table 7.5 Sixty most common lexical types 219
Table 7.6 Rank order of common types in the first interview as a whole and in sections of the first and second interviews dealing with reason for admission 247
Table 7.7 Forty most common lexical types in the first reason for
admission corpus 248
Table 7.8 Forty most common lexical types in the second reason for
admission corpus 249
Table 8.1 Age at admission and days spent in the psychiatric ward at
Milfield Hospital 264
Table 8.2 Gender and race distribution of patients in the psychiatric ward at
Milfield Hospital 264
Table 8.3 Somatic treatments given to patients in the psychiatric ward at Milfield Hospital prior to admission 265
Table 8.4 Sixty most common types in the initial history corpus 270
Table 8.5 Sixty most common lexical types in the initial history corpus 271
Table 8.6 Lay accounts versus previous diagnoses in the initial history text 285
Preface
A visit to the aquarium
I should have been a pair of ragged claws
Scuttling across the floors of silent seas.
- T.S. Eliot
In an article in the British Journal of Medical Psychology, Thomas Szasz (1993a), doyen of the antipsychiatry movement, writes: "It seems to me that no amount of reasoning or research can bridge the gap between tissue and talk, between cellular pathology and language pathology" (p. 65). Szasz's assertion is remarkable for two reasons. The first is that he should once again (cf., Szasz, 1967, 1978, 1993b) choose to build his critique on the use of language in schizophrenia, when schizophrenic speech, or crazy talk as Szasz would call it, is in fact rare. Leff (1993), for example, reports having encountered no more than 50 cases in over 1000 patients diagnosed as schizophrenic. The second is that, unlike what happened when he made similar claims in the 1960s, Szasz's article is almost certain to have no impact on psychiatric practice.
Szasz's own explanation for his choice of crazy talk as key to the argument is that in the absence of real biological markers disordered language continues to be used by psychiatrists as a kind of pseudo-biological marker of thought disorder, which is then equated with brain disorder(1). Thus by removing 'disordered speech' as a legitimate part of the system, Szasz hopes to bring down the whole house of cards. To the extent that he theorises the puzzling ineffectiveness of this strategy, Szasz's reasoning can be summed up in two words: Medical hegemony.
Mainstream psychiatrists themselves, if they could be bothered to take note of Szasz's work, would most probably find other explanations for his continued obsession with the issue of language and for the negligible impact of his critique. Szasz, they might say, does not conduct proper scientific research on mental illness, and is therefore reduced to philosophising about language. He is no longer taken seriously both because of the disastrous consequences when his ideas were implemented in the 1960s, and because biological research on mental illness has progressed to the point where his brand of linguistic nitpicking has become irrelevant.
In this dissertation I attempt to theorise and research the tension between language and biology from a position somewhere between the antipsychiatric (as exemplified by Szasz) and the mainstream psychiatric approach. Like Szasz I take language to be a key site of resistance, but unlike him I focus on the ordinary daily language of patients and physicians, rather than on crazy talk, as that which maintains the system of psychiatric illness. Like mainstream psychiatrists, I assume that patients are to a large extent not free agents, but constrained in what they can say and do, but unlike them I view the constraints as discursive as much as biological, and as affecting the sane as much as the insane.
The substantive problem to which I apply this approach is that of psychiatric chronicity, which translates as readmission in modern hospital psychiatry. My purpose is to demonstrate that chronicity has its own lexicon, syntax and semantics; that the walls of the asylum are fashioned in language, and are therefore susceptible to being linguistically breached, scaled, subverted and deconstructed. In the course of the dissertation I take two steps away from readmission as a problem of overt individual behaviour. First, I trace how chronicity can be viewed as a social construction with a particular contingent history, a history marked by oscillations between confinement and liberation, but more particularly by the increasing influence of 'moral', rather than physical confinement. Second, I trace how this moral confinement becomes real not only in the movement of bodies in and out of the psychiatric hospital, but in the minutiae of the everyday language used by psychiatrists and their patients.
I start with a review of empirical research on readmission (Chapter 1) and suggest instead a possible historical structure (involving an oscillation between pessimistic somatic and optimistic psychosocial views) within which to understand the phenomenon (Chapters 2 and 3). I elaborate this in an attempt at accounting for the somatic orthodoxy which currently holds sway in psychiatry (Chapter 4), evaluate criticisms of such accounts as being insufficiently data-driven (Chapter 5), and review the possible utility of techniques from corpus-based linguistics in responding to these criticisms (Chapter 6). I then apply newly developed techniques to transcripts of interviews with psychiatric patients (Chapter 7) and to psychiatric case notes (Chapter 8). Finally, I reconsider (Chapter 9) the implications of a discourse-based approach to mental illness.
Methodologically, the dissertation attempts to draw on both quantitative and qualitative empirical enquiry, and to speak simultaneously in the idiom of objectivity and of social constructionism. Of all academic disciplines, psychology is perhaps the most difficult to assign to one or the other of what C.P. Snow (1959, 1964) called the "two cultures" of learning: Is it Mr Eliot the banker, the dull but reliable calculator of behavioural interest rates and cognitive amortization values, or Mr Eliot the poet, inventor and exposer of a more forbidding reality below the surface of our routine existence? Thus I am concerned with the cold surfaces of numbers in psychology and with the colder depths of words - and with deconstructing the distance which separates them.
The materials I have used in putting together this dissertation are academic and other publications on topics such as the postmodern ferment in the social sciences, the history of psychiatry, the 'causes' of psychiatric readmission, and qualitative vs quantitative research; transcripts of interviews with patients at a mental hospital; case notes from the psychiatric ward of a general hospital; and ethnographic observation over a number of years in and around South African psychiatry. I have tended to treat published texts with different degrees of piety, taking seriously both the rather bland 'discourse analysis' (Potter & Wetherell, 1987) and the more radical deconstructivism (Parker, 1989a, b) practised by social psychologists interested in language; both mainstream (Kleinman, 1988) and critical (Singer, Baer & Lazarus, 1990) medical anthropology; as well as various other cultural, sociological, and political critiques of medicine and madness. However, texts of the sort that are published in psychiatric and clinical psychology journals I have not engaged on their own terms, using them instead as data for analysis.
According to Gergen (1985) accounts of social constructionism, as this dissertation attempts to be, cannot be empirically warranted. Their success depends on the author's capacity to "invite, compel, stimulate, or delight the audience, and not on criteria of veracity" (p. 272). However, while these are standards by which I would wish this dissertation to be judged, the empirical warrants offered (especially in Chapters 7 and 8) are not included entirely for their entertainment value. At best the dissertation should evoke the same kind of response as would a casual visit to an aquarium, namely mild pleasure upon viewing each new exotic creature - Marble Hatchet, Bleeding Heart Tetra, Kissing Gourami, Green Hi Fin Molly, or, Pair of Ragged Claws - together with a slight stimulation of interest in precise scientific nomenclature and muted scepticism about the degree to which each underwater display approximates imagined real aquatic ecologies.
1. 1 An undated booklet (A member of your family suffers from schizophrenia) published by the Department of Health and Population Development neatly illustrates the process by which crazy talk is turned into disordered thinking: "Such a person may say things you do not expect or understand. He may talk a great deal or loose [sic] the trend of what he is saying. Sometimes it looks as though there are too many thoughts for him to cope with." (p. 3)